Weak Ties, Professional Development and Implications for Companies and Trade Associations

In it's last tour of the Population Health Management Journal, the Disease Management Care Blog neglected to mention the editorial by Paul Terry of StayWell Health Management.

Titled ''The Strength of Weak Ties' Revisited: Achieving True Integration of Disease Management and Lifestyle Management,' Dr. Terry reaches into a backwater of social theory and argues that the cozy, 'tight' and insular ties that characterize like-minded professional relationships paradoxically impair collaboration and stymie social change. What is needed, he argues, are more of the 'weak ties' of loose acquaintances that allow otherwise separate expert networks to access each other's insights and knowledge. He suggests close ties within the disease management and lifestyle management communities are getting in the way of fashioning true comprehensive solutions across the population continuum. His proposed solutions include 1) fostering true multidisciplinary teaming, 2) putting the needs of the population first and 3) transparently sharing all research findings.

The DMCB likes the concept and wonders if this could be taken even further by readers both personally and organizationally.

At the personal level, we're all on the lookout for professional career paths that are likely to lead to fame and fortune. Individuals who can create the weak ties across multiple professional camps will have a leg up in the competition for those future coveted healthcare VP jobs. By networking outside your field of study, you'll be able to gain access to otherwise unavailable insights and use them to you and your organization's advantage. While you risk becoming a jack of all trades and a master of none, if would seem that there is a need for individuals that can crosswalk between disease and lifestyle management, public health, medicine, actuarial sciences, nursing and pharmacy.

Organizationally, it seems to the DMCB that fostering weak ties between the various work units, departments and divisions could contribute to a competitive advantage. This concept should be useful to corporate leaders, who may be otherwise tempted to promote close ties in their workforce.

In addition, there are forums where companies themselves can network, such as trade associations and purchasing groups. Assuming no company can be a member of every organization out there, this social theory would suggest that it makes sense to choose one that offers a high level of diversity. One example that comes to mind is the DMAA, which convenes a broad swath of traditional disease management and lifestyle management organizations, along with a host of other stakeholders. Which brings up another point: business associations that are not insular and instead strive to have a broad membership with weak times are probably the ones that are doing their members the greatest service.

There Are Four Health Insurance Renewal Cycles and Two Elections Between Now and 2014—Could be Sort of Like a “Death By a Thousand Cuts” for the Dems

The Congressional Budget Office (CBO) issued a report today saying that if the Reid bill becomes law the price of non group policies would be about 10 percent to 13 percent higher in 2016 than it would be under current law. The CBO projects that small group and large group premiums would be about the same in 2016 as they would have been anyway as the benefits of the bill would offset some of its

The Senate Democratic Health Care Bill is a “Milestone” on the Road to Cost Containment—If It Is It's a Pretty Small One

The Obama administration is reportedly pleased with a recent Ron Brownstein article in the Atlantic.In it Brownstein praises the Reid Senate health care bill for the steps it takes toward containing costs. He quotes MIT economist Jonathan Gruber who says, “My summary is it's really hard to figure out how to bend the cost curve, but I can't think of a thing to try that they didn't try. They really

Two New Studies Show Telephonic Disease Management Works

When skeptics think about 'disease management' (DM), they think about distant and nurse-filled cubicle farms that put unsuspecting patients through a speed dial version of education-lite. Plumbing the depths of these telephonic knockoffs, critics have made it abundantly clear that don't like what they see: a pseudoscience that confounds patients and antagonizes physicians. They're fed up with the lack of financial provider incentives, lagging technology and ineffective leadership support. It's so bad, 'how to' articles like this have become necessary to help address the physicians' loss of prestige, influence over patient care and income. Policy makers, academics and organized medicine groups have all agreed that the outrageous vendor fees could be better used for other stuff. Like vaccinating upper-class suburban tots. Or paying for motorized wheelchair scooters for affluent octagenarians. Or increasing primary care physicians' fees.

A pox on disease management you say? Stone them?

Think again. Two important publications in the mainstream peer-reviewed medical literature suggest that traditional telephonic disease management is quite effective.

The first is this article, in which researchers from the University of Pittsburgh report the results from a randomized control trial that compares telephonic "collaborative care' (CC) (N=150) versus usual care (N=152) for fresh heart surgery patients that were discharged from one of seven Pittsburgh area hospitals with a surprisingly common side effect of their treatment: active depression (1).

The CC nurses provided 'psychoeducation' in the intervention group that increased awareness of depression treatment options. Backed-up by a psychiatrist/internist team, the nurses also facilitated the patients' treatment decisions. The article includes a description of the CC nurses' roles could have been written as a job description by any of the current for-profit disease management vendors:

'Adheres to evidence-based treatment protocols, supports patients with timely education about their illness, considers patients' prior treatment experiences and current preferences, teaches self-management techniques, actively involves primary care physicians in their patients' care through regular exchanges of real-time information, proactively monitors treatment responses and suggests adjustments when indicated, and facilitates co-management or transfer of care to local mental health specialists when patients do not respond to treatment, have clinically complicated cases, or upon request by the patient or primary care physician.'

Using an approach that is quite similar to any typical disease management vendor program, patients were telephoned every other week for two to four months with calls lasting 15-45 minutes. This was followed by a 'continuation phase' with a call every one to two months. Eight months later, various mood tests showed that the CC group had a greater and statistically significant improvement in psychological well being compared to the usual care group. In looking at the graphs from the study, the Disease Management Care Blog was unable to discern any meaningful difference in the overall rehospitalization rate, though it looks (no 'p' value was reported) like rehospitalizations for cardiovascular disease were considerably lower in the CC patients. CC women were also more likely to being taking antidepressants.

The second is this article, where the Duke University primary care clinics randomly assigned 636 patients to one of four treatments: 1) a telephonic bimonthly 'behavioral intervention' that used the patients' perceived risks, memory ability, literacy, educational level and the quality of the doctor-patient relationship to tailor engagement in the DASH diet (N=160) 2) just a home blood pressure (BP) monitoring device (N=158), 3) both education and a BP device (N=159) or 4) neither (N=159). Two years later, there was an absolute 11% increase in the proportion of patients that had blood pressure under control vs. 7.6% in the blood pressure cuff group vs. 4.3% in the phone call only group. There was no impact on health care costs (2).

First of all, the Disease Management Care Blog thinks both studies are an affirmation of what the mainstream DM vendors have been doing for years. While post-heart surgery depression hasn't been a topic of research, telephonic-based DM for depression in other settings has been shown to have considerable merit. As for hypertension, managed care insurers have known for years that BP control in primary care settings is not what it should be. In response, many DM vendors are selling patient engagement programs that promote the DASH diet with or without blood pressure monitors. Based on the Duke study, it would appear that the managed care organizations can expect and have achieved better blood pressure control with hypertension DM.

Secondly, aha, you ask, but are we getting our money's worth? Neither study 'saved money.' If the cost of the nurses was included, both interventions described above would probably be rated as money losing. While that may be technically 'true,' a) neither study followed patients for a sufficient period of time - it can take longer for a pay-off to accrue, b) commercial DM vendors are much better at identifying, targeting and successfully managing the high risk patients with a higher likelihood of excess costs, c) the interventions above were just for depression or hypertension; modern DM vendors are able to fold in additional care management interventions for other co-morbid conditions that can lead to hospitalization or increase costs and d) maybe, just maybe, the ultimate purpose of DM is not to save money but to increase quality of care at a price point that yields the greatest bang for the dollar. In other words, if depression or hypertension is better treated, maybe it's worth it to pay for it. Stick with usual primary care and you get what you pay for.

Thirdly, critics may point out that both studies above originated in physician-owned, operated and led settings. Fair enough, says the DMCB, but it also knows that primary care physicians in large health care systems are not necessarily more loyal to the 'home office' than any external vendor . In fact, close reading of both studies fails to show that the UPMC or Duke nurses were really all that different from any other external care management initiative. The DMCB doesn't believe the location/ownership of the nurses is what's important. Rather, it's what they do and which patients they do it to.

The DMCB has pointed out for years that telephonic disease management is an important option in the suite of services for caring for populations with chronic illness. It's nice to see that there are now two studies that confirm that perspective.

1. Rollman, B, Herbeck Belnap B, LeMenager MS, Mazumdar S, Houck PR, Counihan PF et al: Telephone-Delivered Collaborative Care for Treating Post-CABG Depression: A Randomized Controlled Trial. JAMA 2009;302(19):2095-2103

2. Bosworth HB, Olsen MK, Grubber JM, Neary AM, Orr MM, Pwers BJ et al: Two Self-management Interventions to Improve Hypertension Control. A Randomized Trial. Ann Intern Med 2009 151(10):687-695

The Latest Population Health Management Journal Summary For Your Summarized Reading Pleasure

Better late than never says the Disease Management Care Blog.

Just like yours, the DMCB's latest copy of the Population Health Management Journal has gone guiltily unread. Unable to resist any longer, it broke out the caffeinated beverages, donned it's reading spectacles and jumped in. It took notes and took no prisoners.

Good thing. The holidays are fast approaching, time is tight and you need know which articles are worth a closer look so you can quote them to the amazement of your coworkers.

James Gill, Ying Xia Chen, Joseph Glutting, James Diamond, Michael Lieberman: Impact of Decision Support in Electronic Medical Records on Lipid Management in Primary Care. Clinics that were already using GE’s ‘Centricity’ electronic medical record (EMR) and were members of the ‘Medical Quality Improvement Consortium’ (MQIC) were randomly assigned to either: a) an interactive point-of-care EMR disease management tool (12 clinics with 26,696 patients), or b) usual use of the EMR (13 clinics with 37,454). The tool consisted of an on-screen ‘pop-up’ that included a warning, patient assessment and patient management prompts. One year later, high risk patients (as determined by ATP-III criteria) were statistically significantly more likely to be tested. However, there was no difference in the rates of blood cholesterol levels being at recommended levels or being on lipid-lowering medications. Moderate and low risk patients were no different in both testing and being at recommended levels. Maybe it was the Centricity EHR, maybe it’s because docs don’t like/respond to pop-ups, maybe there are no financial incentives or maybe the EMR just doesn’t have the healthcare mojo the HIT nudninks would have us believe. Heads up Mr. Blumenthal.

Kurt Angstman, Ramona DeJesus and Mark Williams: Initial Implementation of a Depression Care Manager Model: An Observational Study of Outpatient Utilization in Primary Care Clinics. This is a retrospective study looking at the impact of an ICSI ‘coordinated’ and creatively named ‘Depression Improvement Across Minnesota Offering a New Direction’ (DIAMOND) project that is housed within two Rochester area Mayo Family Clinics with about 19,000 patients. Two care manager nurses were hired to assist in the care of patients with depression (defined as not only having the diagnosis but a PHQ score of 10 or greater). 38 DIAMOND participants were compared to 49 depressed patients who went without the care managers. DIAMOND patients had a higher number of return visits (averaging 1.24 vs. .69 for any reason and averaging .95 vs. .55 for depression) within a month. However, in looking at the proportion with at least one visit, 66% of the DIAMOND patients had a return visit for any cause within a month vs. 37% of controls (a difference that was statistically significant) and 55% of the DIAMOND patients had a return visit for depression in one month vs. 32.7% of the controls (not statistically significant). While the authors pronounced DIAMOND a success, the inability to find a statistically significant increase in the proportion of patients with follow-up visits for depression – the basis of a key HEDIS measure – makes the DMCB think otherwise about the 'success.'

Tine Hansen-Turton, Caroline Ridgway Sandra Festa Ryan and David Nash: Convenient Care Clinics: The Future of Accessible Health Care – The Formation Years 2006-2008. This is a thoroughly referenced history, description, review and editorial for Convenient Care Clinics (CCCs). If you can get past the marketing infomercial-like framing (the early ‘fledgling years,’ or ‘pleased’ consumers ‘ have ‘driven ….the increase in third party contracting, or ‘the core values’ are ‘quality, accessibility, price transparency and affordability,’ or CCCs ‘resonate with parents’ etc. etc.) you can learn about the Convenient Care Association, Harris polls, the growth of the industry, a RAND study that purports to show CCCs Are A Righteous And Good Thing, the underlying business model and the regulatory challenges.


Jane Stacy, Seven Schwartz, Daniel Ershoff, Marilyn Standifer Shreve: Incorporating Tailored Interactive Patient Solutions Using Interactive Voice Response Technology to Improve Statin Adherence: Results of a Randomized Clinical Trial in a Managed Care Setting. Humana randomized enrollees on statins to either 1) three behaviorally-based highly personalized interactive voice response (IVR) phone calls coupled with personalized mailed materials (N=253) or 2) one IVR call and generic mailed materials (N=244). At six months, the group with the high intensity IVR was more likely to have submitted a pharmacy claim for their statin (implying they were taking their pills) than the lower intensity group: 70% vs. 61%. Other measures of medication compliance were also statistically significantly different. The authors state their intervention consisting of ‘an amalgam of discrete elements borrowed from various evidence-base adherence-enhancing strategies ….based on multiple behavioral theories,’ works, but its vagueness makes it difficult for the reader to assess whether the intervention is truly generalizable. Readers may also wonder why the control group didn’t get three low intensity phone calls: it’s possible it was the calls alone, not the content, that led to the 10% absolute improvement seen in the study population. (As an aside, IVR was used to recruit potential candidates for participation in the research project and ‘73% could not be contacted by the IVR system after three months’ of multiple attempts. Is IVR the blanket communication tool that many believe it is?)


Yujing Shen, Usha Sambamoorthi, Mangala Rajan, Donald Miller, Ranjana Banerjea, Leonard Pogach: Obesity and Expenditures Among Elderly Veterans Health Administration Users with Diabetes. This study used the 1999 Large Health Survey of Veteran Enrollees (LHSVE) and the 1999 Diabetes Epidemiology Cohort (DEpiC) to assess the interplay between diabetes, accompanying obesity and the costs among VA patients who were also enrolled in Medicare. Only 21% had a normal body mass index (BMI); the remainder were overweight (48%), obese (23%) or morbidly obese (9%). While you would think that excess weight would be associated with higher costs, that’s not what was found: a normal BMI had more than $10,000 in yearly expenditures, followed by overweight ($7500), obese ($6600) and morbidly obese ($6700). The authors looked into the categories of claims expenses and could find no simple explanation, summing things up by saying a normal BMI may be associated with ‘poorer health.’ While the findings are counterintuitive, the authors point out there are other studies that show a reverse relationship between weight and costs among elderly persons with chronic illness. Maybe the widespread assumption that there is a ROI from weight loss and that this a reason to include it in care management for an elderly population should be revisited.


Brian Leas, Bettina Berman, Kathryn Kash, Albert Crawford, Richard Toner, Neil Goldfarb and David Nash: Quality Measurement in Diabetes Care. Did you know there are multiple organizations promulgating their own methodologies for assessing quality in diabetes care? Of course you did, but the extent of the problem may be greater than you think. It’s tough enough that different groups (like the NCQA or the National Quality Forum and others) recommend different measures. For measures where there is agreement (for example hemoglobin A1c), there are differing standards over the determination of the numerator and denominator, the target goal or the time frame. After surveying the various quality standards organizations, the authors then asked an expert group of ‘key informants’ if they found the complexity problematic. Short answer: yes. In addition to better ‘harmonization,’ the authors recommend that some missing measures be developed, such as assessments of interventions for ‘pre’-diabetes, ‘population-based’ metrics (not just the patients with a claim or a provider visit with an index condition), better attention to measures in the unemployed or uninsured populations, patient-centric measures and assessments of access to care. Good idea says the DMCB.


Roxana Maffei, Daniel Burciago and Kim Dunn: Determining Business Models for Financial Sustainability in Regional Health Information Organizations (RHIOs): A Review. If you’re interested in boning up on Regional Health Information Organizations (RHIOs), this is the article for you. Reports of their death have been greatly exaggerated but their economics remain murky. Among the few RHIOs that have survived, success seems to be associated with being a free standing organization with a business model predicated on membership fees (local health organizations involved in exchanging data pay a fee to belong, i.e., pay to play) and transaction fees (billing the participating organizations based on the number or type of transactions occurring). This article points out that this is still very much a work in progress. Stay turned.

Don't Rationalize Busting the Budget--Start Over

I detect a growing rationalization among supporters of the Democratic health care bills: The recent flare-up over when a woman should have a mammogram proves we are nowhere near ready to pass a health care reform bill that will actually control costs. So, why bother?You would be hard pressed to find any health policy expert who isn’t disappointed that cost containment has fallen off the health

Breast Cancer Performance

While Disease Management Care Blog readers may be disappointed by the disease detection performance of mammography, how government performs in processing research findings or how scientists perform in interpreting data, we can all agree that much work remains.

The folks at St. Vincent's in Oregon reminds us of that with this performance of their own.

Enjoy.

Hat Tip to HBR

Primary Care Models That Are Outside the Mainstream: Will Health Reform Be Flexible Enough (and disease management see the opportunity?)

Thanks to a combination of colleagues' e-mails*, media outreach and alerts, the Disease Management Care Blog has become reacquainted with some interesting primary care models that aren't in the mainstream of healthcare reform.

They may be worth thinking about.

First off, the Philadelphia Inquirer has this report on an insurer owned and operated primary care clinic. The DMCB recalls that during the 1990's, some HMOs branded and operated their own outpatient networks. With the fall of capitation, the concept fell into disfavor.

Or how about the concept of 'Direct Primary Care,' where, for as little as $49 per month, patients can access primary, preventive and chronic care. If the DMCB understands this right, the DPC folks want to cut the insurer-middleman out entirely and effectively let each patient pay their own capitation. Could this arrangment make limited forms of health insurance a good option and a lot cheaper? This Wall Street Journal editorialist would probably say yes.

There's also the notion of the community based medical home, where a cluster of primary care physicians refer to and rely on a separate network of care management nurses. This is very nicely described in a recent editorial by Helene Levens Lipton appearing in the November 23 Archives of Internal Medicine. A good example of this can be found in Vermont and their shared 'Community Health Teams.'

Once again, the DMCB worries that whatever passes for health reform may not be able to accomodate the primary care work-in-progress. All of the ideas described above have their merits and, for some patients in some markets, may be a perfectly satisfactory option.

Last but not least. the 'community based' feature of a medical home could represent an important opportunity for the care/disease management vendors.

*you know who you are: thanks!

A Health Care Surtax on the Rich: It Ain't So Easy

The Disease Management Care Blog has been taking a tour of the Senate Health Reform Bill currently up for debate. Blowing tanks and diving all the way to the end, it found this verbatim language in Section 9015 on how the rich will be subject to a surtax:

(2) ADDITIONAL TAX.—In addition to the tax imposed by paragraph (1)....there is hereby imposed on every taxpayer (other than a corporation, estate, or trust) a tax equal to 0.5 percent of wages which are received with respect to employment during any taxable year beginning after December 31, 2012, and which are in excess of (A) in the case of a joint return, $250,000, and (B) in any other case, $200,000.

Web opposition to a health care surtax seems to be either a) economic: the Heritage Foundation is typical, arguing it will stunt economic growth and contribute to unemployment, just look what it did to those silly beret-wearing bicycle-riding Europeans and b) prognostic: while the rich-surtax is not singled out by this Wall Street Journal editorial, dismay over the need for a plethora of revenue sources that reminds detractors of how the word 'trillion' has entered popular culture faster than our President can humbly bow to foreign heads of state.

The contrarian DMCB wonders, however, about the fairness. While we live in a country of progressive taxation thanks to a) the rich deriving greater benefit from living in the U.S., b) a tax on the upper bounds of income being less painful (i.e., there's 'less marginal utility') c) this is income that is less likely to be productive, d) oh heck, they had a free ride during the Bush years and e) it's disposable income (among other arguments). Yet, up until now we haven't really subjected insurance premiums to a progressive levy.

Generally, premiums have been tied to the size of the risk pool divvied up by the proportional degree of risk. Thinking of car insurance, this can simplistically be defined by the a) magnitude of the potential loss (a totaled Rolls Royce versus a totaled Hyundai) and b) the liklihood of the loss (a teenager with 3 prior accidents vs. the DMCB spouse).

Given the ways things are going, we're all going to be using the health insurance equivalent of a Hyundai and even if you're in good health, it looks like you'll pay more if your excess income can serve to avoid a Federal deficit. In thinking about insurance in general, this has important policy implications. For example, could this be the solution to hurricane insurance, where U.S. taxpayers are on the hook for Florida's coastal areas?

Poicy aside, while the current plan is to tax the rich, stubborn health cost inflation could tempt future Congresses toward a progressive tax involving lower thresholds of income. Last but not least, $200,000 to $250,000 may seem like a lot now, it may not be for more and more of us if inflation takes over.

Progressive premiums: Fair? Good policy? In your interest? You be the judge.

The Democratic Health Care Effort--A Political "Charge of the Light Brigade?"

The latest polls are an unmitigated disaster for Democrats even as they're on a fast track to get their health care legislation passed.This from Rasmussen this morning:“Just 38% of voters now favor the health care plan proposed by President Obama and congressional Democrats. That’s the lowest level of support measured for the plan in nearly two dozen tracking polls conducted since June.“The

The Mammography Controversy: How Government Runs An Insurance Benefit

What took the the US Preventive Service Task Force so long?

Years ago, the young and inexperienced medical director Disease Management Care Blog became aware of a burgeoning body of literature (examples here and here) questioning the value of mammography for women less than age 50 years. Its health plan considered the option of denying coverage of mammograms in this age group, but ultimately decided against it. We calculated that the HEDIS, marketing, public relations and political downside of reducing a women's health insurance benefit was just too radioactive in our network. Based on an assessment of what our customers wanted, we put that idea down and slowly backed away. Problem solved - quietly and more than 10 years ago.

The 2009 mammography controversy shows how difficult it is to create a one-size fits all insurance benefit that reconciles the a) science, b) market expectations and c) politics. As government increases its role in the nation's health care, readers can expect the same slowness and rhetoric to intrude into countless other coverage decisions.

In a perfect world, women could choose an insurance plan that meets their price point (the monthly premium) and benefit plan (mammograms expensively covered every year vs. another less expensive option). As we all know, all Americans should have anything they want, just so long as they pay for it. Ms. Sebelius is once again reminding us that in rhetoric-driven government dominated health care, all Americans should have anything they want, and we're all going to pay for it.

One last point: this should give readers some insight into HHS Secretary Sebelius' pain. Ironically, during her confirmation hearings Sebelius was roughed up by Senators who were fearful that she'd use comparative effectiveness research to interfere with the doctor-patient relationship. Her flexible stance on mammography shows she is keeping her word.

All things considered, good for her.

Time for Public Health Video Announcements for Cell Phones

What a great idea.

It may already be out there, but a colleague of the Disease Management Care Blog pointed out that it's only a matter of time until video (for example) functionality becomes a routine feature of all cell phones. What's more, based on usage, the phone companies will be able to identify individual preferences and interests. Companies are undoubtedly gearing up for this and are preparing to 'push' their brands on an unsuspecting public by channeling specific individualized content to the end-user. It will be hated by consumers. It will also be very successful.

Why not, she asks, plan on doing the same thing in the name of public and population health?

After all, parts of the U.S. government (an example is the Centers for Disease Control and Prevention or 'CDC') are also in the business of molding consumer behavior. Compared to pharma's ubiquitous cholesterol-drug T.V. advertising, however, the CDC's written materials are stupendously boring. Any video content is conspicuously absent both on CDC.gov and YouTube web sites.

Note to the Feds: if you all really intend to be leaders in U.S. healthcare and continue to want to educate in the name of public health, you need to anticipate where your 'market' is going. It's time to start planning on the creation of short, focused, engaging and, most of all, trusted video content for cell phones that can be 'pushed' toward consumers interested in topics such as weight control, treatment of diabetes or lowering their high blood pressure.

How Can Harry Reid Keep a Straight Face Telling Us His Health Bill Will Reduce the Deficit?

The accounting gimmickry in Harry Reid’s Senate health bill is astounding even by Capitol Hill standards.Reid says his bill will cost $850 billion and reduce the deficit by $130 billion—all over ten years.Based upon the outline Reid gave the CBO that could well be right. But let’s look at it further:Reid delays most of the spending in the bill to 2014—a year longer than in the House. More

Another Media Failure Over A Questionable Study: Medicare Associated With Increased Trauma Deaths? No Better Than NOT Having Insurance?

Did you know that Americans with Medicare health insurance have a higher adjusted mortality rate from trauma compared to persons with commercial insurance?

The Disease Management Care Blog explains.

According to numerous news outlets such as ABC News, MSNBC, the Huffington Post and Reuters, a study's been published that shows that not being insured at the time of hospitalization for trauma leads to a higher death rate. Adding to the drumbeat of liberal dismay over lives lost for lack of a public option, this research by Rosen and colleagues, published in the prestigious Archives of Surgery, shows there are 'sky high' death rates (Democratic Underground) that are 'shocking' (Daily Kos) and could be the evil consquence of 'less enthusiasm on the part of providers.... once it was realized they would not be compensated' (Physicians for a National Health Program). Of course, the luster of this scientific report was only enhanced further by the inclusion as author of superstar surgeon Atul Gawande, that (in)famous author of the New Yorker article that used the shortcomings of single outlier McAllen Texas to call the entire U.S. healthcare system to task.

Like the media, should the DMCB be impressed by a published study in a prestigious journal by rock star authors? Just take their word for it? Actually no, because the purpose of peer reviewed literature is to allow readers to assess the research findings and decide for themselves. It's called trust, but verify.

So, unlike the attention-deficit disordered denizens of the oxygen-deprived mediasphere, the DMCB responded in a novel way. It decided to pull the study and actually take the time to read it.

Here's what it found. Data from 2.7 million U.S. hospitalized patients were mined, looking for correlations between death and insurance status while mathematically neutralizing the effect of age, gender, race, the type of trauma center as well as the type of trauma. Persistent and statistically significant correlations were found between dying and a) increasing age, b) race (being black plus young) c) the severity and mechanism of the trauma (for example penetrating injury is bad), d) an increased number of comorbid illnesses and e) insurance status.

In fact, two types of insurance status had statically significant associations with a higher death rate: 1) not having any health insurance and 2) being on Medicare. If you look at the graphic from the study, you'll see that compared to commercial insurance, Medicare had a statistically significant odds ratio of a higher death at about 1.5, while no insurance was also high at 1.8. Look carefully, because the lack of an asterix means the finding is statistically significant.

The DMCB thoughts about the implications:

1) What should the 'comparator' be? We don't know. One separate study used managed care as the baseline while this other study used Medicare. Since there is no generally accepted baseline for research like this, the author's choice of using commerical insurance as the gold standard in this article made not having insurance look bad. If Medicare had been the standard, persons without health insurance probably would not have turned out to be worse. Even more ironically, managed care (accounting for the majority of U.S. commercial insurance) would have turned out looking better. Interestingly, the authors neglected tell us why they chose this approach.

2) Are the authors (and the Archives' editors) politically motivated? There is one explanation for the use of the commerical comparator: it's a ringer that makes everyone else look bad. What's more, failing to mention that Medicare insurance status was also associated with lower survival rates is either a monumental lapse or an intentional attempt to understate a finding that is also important. Knowing that policy makers, media and many readers won't get past the title ('Downwardly Mobile. The Accidental Cost of Being Uninsured'), the abstract (no mention) and some juicy interviews, only half the story is being told. The full story is that when it comes to trauma care, giving everyone Medicare-style insurance is no better than no health insurance at all. This is a great example of framing, especially since the asterix seem to call the readers' attention away from Medicare's inconvenient......

3) Are some other potential explanations? While a lack of health insurance is associated with poor health outcomes, it is also known that having poor health leads to lack of insurance. Accordingly, the mathematical 'signal' from being nominally 'uninsured' in this study may really be due to the influence of unmeasured health or other issues that were not captured in the data base. That's called systematic bias and it went completely unmentioned as a potentional shortcoming in the authors' discussion of their results. Assuming the results are real, the DMCB believes post-hospitalization care (rehab and outpatient) is generally not well covered and coordinated under Medicare, which in turn leads to problems.

4) Association is not necessarily causality. Just because not having insurance is associated with death from trauma doesn't mean giving this poverty-prone population insurance will reverse things any more than the association between white hair and more heart attacks (due to age) can be fixed by dying everyone's hair black. Likewise unmentioned by the authors.

Once again, the media has demonstrated its shortcomings. What's more, the peer reviewed process has shown how necessary it is to look at the results for yourself: you can't always count on the authors or the editors to look at all sides of the data or rise above their prejudices. Lastly, there's an old joke out there that is sometimes told by us general internists: how do you create a double blind study? Get two or more surgeons involved.

This publication was double binded.

At the time of this posting, the DMCB had an email into the author asking for feedback. None yet

Obesity: Are We Dealing With A Growing Addiction? Implications for Population Health Management Strategies

The Disease Management Care Blog welcomes Rose Maljanian, who is President & CEO of Strategic Health Equations, LLC. She has 25 years of health care experience and has served in senior leadership roles in managed care, specialty care management and health delivery systems

By Rose Maljanian

Today, yet another important and credible set of data from America’s Health Rankings have been released. It is telling us that obesity is on the rise and that the costs and health implications associated with it will devastate the financial viability of the US health system as we know it. The Urban Institute also recently released a report calling for more focus on obesity in developing health policy so that we can make headway on curbing this alarming trend.

In response, disease management and population health management companies, along with their contracting health plan, government and employer partners, are hard at work designing and deploying obesity programs. These are offering individualized health coaching to address the issue and in most cases providing incentives versus cost to participate. These programs have demonstrated some success, but have few resources in the way of evidence based practice (EBP)guidelines. They have yet to demonstrate definitive results such as those from the EBPs for diabetes or coronary artery disease medication management. Further, these programs and their staffs are fighting gravity when it comes to what we are calling behavior change because of the environment, social networks/norms, and the lack of serious medical attention often given to obesity.

If we are going to make serious headway, we need to abandon the notion that weight is a vanity issue or that obesity is solely a lifestyle choice that we as a society can all live with. While the evidence to support obesity as a condition of addiction is limited to nonexistent, the parallels to other addictions such as drug and alcohol are undeniable.

We now have evidence that fat cells, particularly those deposited centrally, are active metabolic (versus 'dormant') cells. These cells release chemicals that disrupt the normal hunger center in the brain and cause cravings even when a negative calorie balance does not exist. Thus, people consume larger than needed serving sizes high in fat and calories content while fully understanding that each bite puts them in further jeopardy of early disease and death. In compromised economic times, weight gain may put further stress on families due to the expense of food or need for new clothing because of size change. Their impairments can limit their ability at work or render them unable to perform certain types of work, which only further limits their economic future. Social activities which they previously enjoyed with friends, children and grandchildren may now be foregone or at least put at risk. The problem can contribute to compromising a relationship and even a marriage.

Continuing this negative behavior when it has these kinds of life consequences are a classic sign of addiction when it comes to alcohol and drugs.

Most would agree that allowing such adverse sequelae to build defies logic. Few people would say that an individual would consciously and regularly choose an extra cupcake or cheeseburger over their ability to work, achieve economic stability or success, enjoy time with their loved ones or be available and capable to help others in need.

Since today there are no magic bullets in surgeries or drugs that are suitable for the large numbers of people that need our help, through research we need to build an evidence base to support effective treatment that addresses the possibility that we are dealing with a sort of addiction of enormous magnitude in a very challenging circumstance and where abstinence from the “substance” altogether is not an option.

In the meantime, steps to address obesity as a serious medical and behavioral issue with addiction-based approaches are warranted. Providers can help by formally diagnosing the problem, providing treatment options and doing everything in their power to help people take charge, such as encouraging participation in programs that provide ongoing support. Payers can continue to advance the alignment of benefit designs to support diagnosis and treatment and incent participation in programs that achieve results. And finally, each individual must do their part to get help and help others before the already out of hand problem of obesity collapses our health care system and the economic viability of our country.

Why Isn't the Press Talking About Affordability--For "Ordinary Folks"?

I thought Trudy Lieberman hit the nail on the head in a post she did yesterday at the Columbia Journalism Review entitled, "Missing Persons--How Will Reform Affect Ordinary Folks." Here is a small part of it:The media have talked about affordability mostly in the context of whether the country can afford reform, not whether individuals can afford it. It’s easier for a reporter to write about

Atlasians vs. Cooperites: Poverty and the Dartmouth Atlas

Dr. Richard Cooper continues to generate controversy on the Kaiser Health News site and in the latest issue of Managed Care Magazine. Of course, regular readers of the Disease Management Care Blog are unsurprised, because they were given a heads up about this tempest in a theoretical teacup, this duel of dons, this locking of learned horns, this wrestling of wonks months ago.

The DMCB efficiently explains.

The Dartmouth Atlas folks are holding firm to their assertion that regional variations in Medicare spending cannot be explained by demographic factors or the regional burden of illness. Since healthcare in many areas of the country cost more and have nothing to show for it compared to cheaper areas, the Atlasians assert this otherwise unexplained discrepancy must be due to subjective patient and physician preferences. These unecessary preferences are bankrupting the country.

Not so says the professor from the University of Pennsylvania. When regional variations in the degree of poverty are superimposed on the local health care systems, it turns out that hospitals in poor areas can't attract the human or financial capital to adequately care for persons with and without Medicare, resulting in greater inefficiencies caring for a much sicker population that needs a lot more health care. The Cooperites believe we are getting our money's worth and punishing these hospitals with reduced payments is foolhardy. Not recognizing this will cause hospitals to go bankrupt and risks having providers refuse to see patients with Medicare.

One reason why Dr. Cooper's perspectives may gain some traction is because smart hospital Boards usually have good relationships with their Congressmen. If they're doing their job, they'll remind their a Representative or a Senator that this is the perfect excuse to secure better funding for the local Deficit Memorial Hospital.

One reason why the DMCB likes Dr. Cooper's perspective is not just because it rings true, but because the Atlasians turned to the 'preferences' hypothesis to explain the 'unexplained' variation. While there may be evidence for the former, the hypothesis that patient and physician preferences explain the rest seems convenient, makes sense but unproven. Dr. Cooper fills the some of the unexplained void by pointing out that regional poverty hasn't been fully accounted for.

Maybe they're both right with an answer somewhere in between, but the DMCB wants to see this statistical skirmishing, this clash of the savants continue.

Tally ho.

The Outlook for a Health Care Bill in 2009

Readers of this blog know of my yearlong pessimism over our getting a trillion dollar health care bill in 2009.With the historic passage of the House bill, are we now on our way to a big health care bill in 2009—or even by early 2010?Clearly, Democrats desperately want to pass a bill. Given their compromise over abortion and the neutering of the public option in the House legislation—things most

Informed Refusal: The Doctor Told Me To Come Back When I Had Health Insurance

You're probably familiar with this unlikely and oft-quoted scenario. Patient with disease sees doctor, who peforms a wallet biopsy. After determining the hapless sap is unlikely to pay for the needed medical diagnostic procedure or treatment, the doctor says 'come back when you have health insurance.'

At least that's what the media says.

The Disease Management Care Blog thinks the reality is far more complex:

Doctor: 'How can I help you?'

Patient: 'I saw blood in my [insert name of body fluid] .'

Doctor: 'You're going to need additional testing.'

Patient: I don't have health insurance, so how much is it going to cost me?'

Doctor: 'Well a [insert name of organ]oscopy will cost [insert number] [insert hundreds or thousands] of dollars.

Patient: 'I can't afford that.'

Doctor: 'You can't afford not to have that. Get it done and worry about paying for it later. I'm sure something can be arranged.'

Patient: 'It isn't going to happen. No way can I pay for it, I'm already up to my ears in debt.'

Doctor: 'The test can't be done for free. I strongly advise you to get it done'

Patient: 'No can do.'

Doctor: 'Well, why don't you come back when you have health insurance.'

Years later, when the patient's cancer has progressed to its terminal stages, he is asked how the early symptoms were ignored. The patient's response:

'The doctor told me to come back when I had health insurance.'

The Disease Management Care Blog has seen many patients without health insurance and never dismissed them after a negative 'wallet biopsy'. The typical physician doesn't either. Instead, after confronting the sticker shock of today's real health care costs, it's the patients who often chose to forgo their physician's recommendations based on financial considerations. Weeks, months or years later, what patients remember is how their lack of health insurance put affordability out of reach.

It's been known for a long time that patient recall of the details of past physician encounters is often at variance with what is written in the medical record. When it comes to smoking cessation counseling, this study indicates patient recall tends to be high. On the other hand, recall about the details of the advantages and disadvantages of spinal surgery can be surprisingly low. To complicate things further, recall may be influenced by ethnicity. Of course, not only is patient recall inaccurate, but physician documentation of what happens during the course of a clinic visit often leaves much to be desired. Fixing this shortcoming (for example, with the use of decision supported 'smart forms') is among the many supposed advantages of the electronic record.

The DMCB searched the published literature to see if there were any studies that compared patient recall of the details of what physicians really say about their patient's lack of insurance, what they write in the medical record and what their patients actually remember. There are none. Given the media's less-than-perfect track record on reporting health care in general, the problem may be way overblown.

Some potential solutions:

For the young academics casting about for a research project: use the same 'patient recall' methdology used on prior studies to scientifically compare what really happens to what patients remember in 'no health insurance' discussions. This is very publishable.

For news media: understand that what patients tell you about past conversations with physicians can be inaccurate, if not superficial. Ditto what physicians write in the chart. You are doing a disservice if you give into your biased assumptions and don't dig deeper.

For physicians: if a patient has no health insurance refuses a recommendation on the basis of out of pocket costs for lack of health insurance, approach it like your would informed refusal and take the effort - as always - to document everything. Since physicians typically say much more than 'come back when you have insurance,' the misinterpretation of that phrase makes the DMCB think it should be abandoned and never used in a medical record (unless thats what you really said, you heel).

For electronic health record vendors and CIOs: Develop a 'smart form' that can be used by physicians when they are treating a patient who refuses a recommendation due to financial reasons. For example, 'After discussion of the risks, benefits and alternatives to [insert name of test, diagnostic procedure or treatment here] including the possibility of disease progression and death, the patient, due to financial considerations and the lack of insurance coverage, decided to forego my recommendations. The patient was informed about the need to seek alternative financing alternatives and indicated understanding about that need. The patient was strongly encouraged to return in the near or distant future if there is any change in the decision to forgo my recommendation because of financial considerations.'

For readers: Next time your read about an anecdote about greedy physicians telling patients to come back when they have insurance, be skeptical. There is probably far more to the story.

The End of the "Robust" Public Option and the Potential for "Robust" Cost Containment?

Two things happened this week that in tandem have the potential to lead to a compromise over a health care bill.First, there are unconfirmed reports that Senate Majority Leader Reid is leaning toward offering the neutered version of the public option like that in the House--not tied to Medicare rates, providers not required to participate, and provider reimbursement rates negotiated.The second

The Core Issues in Health Reform

Want a short summary cheat sheet of the core issues that are likely to be included in the final version of health care reform? Thank Paul Ginsberg's short article in the New England Journal of Medicine. Thank the Disease Management Care Blog for giving you an even shorter summary:

1. Expansion of the number of people with insurance: likely to turn out to be a blend of Medicaid and private market subsidies. All that remains is reconciling the more conservative fiscal considerations of the Senate versus the more generous House version.

2. Individual and small market insurance reform: look for 'actuarially equivalent' insurance options being offered through state exchanges with guaranteed issue and a coverage mandate. Right now, our elected representatives are hard at work reconciling that mandate with the level of insurance subsidies: the tougher the penalties, the higher the subsidy.

3. Purchasing of 'high value' care: the Achilles Heel in all this is the risk that health care efficiency will be increased by sacrificing quality. Time will tell if new versions of capitation, payments per episodes, efforts to reduce Congressional meddling, support for health information technology, comparative effectiveness research and prevention will pay off in bending the curve.

4. Tax increases: right now it looks as if there will be a combination of tax increases for high income individuals (the House version) and taxing high end health insurance policies (the Senate version).

Two other points:

Senator Harry Reid (D-NV) has definitely signalled that the Senate may not pass a bill until after Christmas. This may reduce the prognosis for health care reform, but the Disease Management Care Blog doesn't think that will be a lot.

While it will be up to the Conference Committee to reconcile the House and Senate versions and finally give the DMCB a likely description of what health reform will really look like, much important work will need to be done in writing the regulations, creating the organizations and writing legislation to deal with unforeseen consequences.

In other words, if health reform passes, the real work will have only just begun.

from xkcd.com.

15 movies that stick with you

This is a meme that has been doing the rounds on Facebook. I posted it there yesterday but I am too tired and lazy to write anything original today thought it worth sharing with the rest of the world

Rules: Don't take too long to think about it. Fifteen movies you've seen that will always stick with you. First fifteen you can recall in no more than fifteen minutes.

You can participate in the comments or leave a link to your own blog.

1. Gallipoli
2. Fast Times at Ridgemont High
3. An Officer an A Gentleman
4. El Norte
5. The Killing Fields
6. Swimming to Cambodia
7. The Princess Bride
8. Grease
9. Priscilla Queen of the Desert
10. The Breakfast Club
11. Rachel Getting Married
12. History of the World Part 1
13. The Producers (the original version)
14. The Thomas Crowne Affair
15. Mamma Mia

Latest Health Wonk Review Is Up!

Louise of the Colorado Health Insurance Insider has a marvelous summary of this week's Health Wonk Review, accompanied by telling Simpsons graphics. Highly readable, well edited and linked up nicely, everything you'd want to know about many of the latest developments in health care policy is just a click away. Check it out.

Three Years Of Medical Home Demonstration Preparation Down the Drain?

By Vince Kuraitis & Jaan Sidorov

You'd think if anyone were disappointed at the shelving of the Medicare Medical Home Demonstration (MMHD) in favor of the Multi-Payer Advanced Primary Care Initiative (MAPCI), it would be the primary care physicians.

However, we pick up on no signs of discontent.

After 3 long years of anticipation, secrecy and considerable work by multiple stakeholders on the MMHD, including all of the major primary care physician organizations, you’d think doctors should be having an Animal House Bluto Blutarski-like reaction to this sudden shift in Medicare policy.

In fact, based on some informal conversations with many of the organized physician groups’ leaders, we are finding that most doctors are actually pleased with the recent developments.

What's going on here? What does this tell us about what we’ve we learned about the patient centered medical home (PCMH) and Medicare's new direction?

• Challenges of the PCMH’s Business Model Come to Light. Most of all, we believe that over time, the challenges of basing the PCMH business model on reduced costs became increasingly well understood. Based on preliminary information coming out of the PCPCC pilots and early peer review publications along with greater scrutiny of many of the past studies that were being taken for granted, we suspect that there was a growing realization that a MMHD would turn out like the star-crossed disease management Medicare Health Support Demo. This alone would have jeopardized the long-term prospects of implementing PCMH in Medicare.

• Many PCMH Details Yet to Be Worked Out. While the PCMH "concept" has been widely accepted and embraced since 2006, many operational "devil’s in the details" have yet to be developed. Incorporating these into a full-fledged multi-State Demo was probably turning out to be far more complicated than originally anticipated.

• Small/Medium Physician Groups Could Struggle With Infrastructure Required by MMHD. It’s unrealistic to expect a high percentage of small independent physician-owned groups which, by the way, deliver 75% of patient visits in U.S. today, to implement the PCMH. The MMHD required individual physician groups to develop an extensive disease/care management infrastructure and anticipated physicians would hire and supervise nurse care managers to manage their sickest patients. Because this part of the market is so highly fragmented, we think it was becoming increasingly apparently that it was not scalable across large geographies.

• Questionable Physician Interest. We also think that while there were many physicians that were very interested in developing a PCMH, many were also disinterested.

• Medicare Demonstrations As “Change Agents.” We also wonder if there was growing realization that a prospective randomized control trial was an unwieldy challenge for CMS. Data management for multiple primary care sites spread over eight States would be daunting for any research group, including one with CMS’ resources.

• Need/Opportunity for Physicians to Sync With ACOs. Last but not least, the Obama Administration seems more interested in making the Accountable Care Organization (ACO) the lead dog in health care reform. ACOs can incorporate and support many of the care management activities of the PCMHs and, with some tweaking, we believe these models of care are highly synergistic. In fact, evolving ACOs seem extremely provider friendly and offer primary care physicians the opportunity to have an important voice in regional delivery system development.

All things considered, we suggest that CMS and the primary care physicians are considering that it makes more sense to conceptualize all care management activities as a "public utility" – resources that can be shared across multiple physician groups. Perhaps there is growing realization that the PCMH is still in evolution and that much work remains. Accordingly, showing a more flexible approach in ‘piloting’ medical homes, working with other payors and allowing ACOs to support the PCMH is a more viable approach.

The major stumbling block that we can see at this time is whether the small, independent physician practices will readily ally themselves with ACOs and accept a partnership with them over the creation of PCMH’s. That depends on the details of health reform legislation, the local culture in the ACOs and the impact of physician leadership. While the details of MAPCI have yet to be worked out, we believe these questions are best answered in numerous pilots, where Medicare and the physicians can strive to find out what works and what doesn’t work.

So, from the physicians’ standpoint, what’s there not to like?

my husband's chest

You don't need to tell me how lucky I am.

I have a roof over my head, great medical care and I'm surrounded by people who love me.

And don't think I forget how very lucky I am to be alive at all. Why did I get to go into remission? Why me? I am indeed very fortunate.

But there are times when I do feel sad that I will never put this cancer behind me. I feel the toll ongoing treatment takes on my body and my emotional well being.

So last night I stood in my kitchen, with my head on my husband's chest (we say we were built for each other. My head lands flat on his chest and tucks under his chin). He put his arms around me and we just stood there, breathing together.

He didn't need to say anything. He understood my frustration. Only a few hours before I was finallly feeling sharp and healthy and energized. And then, after chemo, I stood in his arms, feeling sick and more than a little shaky.

He didn't remind me how lucky I am.

But I know it.

The Best Health Care Idea All Year

Out of almost nowhere has come momentum for a proposal to create a bipartisan entitlement and tax commission to draft proposals to control the long-term costs of Social Security, Medicare, and Medicaid. The idea would require the Congress to quickly vote the recommendations up or down via a super majority vote.The idea isn't new--proposals for a such a commission have been around for a

Another Reminder that Integrated Delivery Systems Are Not All That

The Disease Management Care Bog is not in the habit of handicapping health care legislation, but it did check in with one of the information markets. The prospect of passage seems to be less than the prevailing spin would suggest.

If one rationale of health care reform is to disseminate the superior performance of integrated delivery systems (IDS), readers may want to check out this largely underreported study in the latest issue of the American Journal of Managed Care. While the 'definition' of a delay in radiation treatment following surgery for breast cancer remains hazy, two months not only 'seems' like a long time but there are data that suggests it can affect survival. According to Taffet Gold et al, IDS' overall rate of a 14% delay of two months or more is no better or worse than what has been reported in other settings.

Of course, this is just one study and there is considerable literature in support of IDS. Ultimately, however, we still don't know if the importation of IDS into areas of the U.S. that are struggling with high cost or low quality or high variation would be the panacea some would like. The American Journal of Managed Care article above reminds us of that inconvenient truth.

Image from Wikipedia Commons

The Disease Management Care Blog Learns A New Term: 'Decremental Cost Effectiveness'

Dennis Hopper, a Disease Management Care Blog fav thanks to his roles as a 60's addled motorcyclist in Easy Rider, a manipulative scheming huckster in Boiling Point and a sociopathic bomber in Speed, is battling prostate cancer.

The DMCB wishes him all the best and not just because Mr. Hopper was an inspiration for an early DMCB post.

And thanks to another Dennis Hopper quote:

Pop quiz, hotshot. There's a bomb on a bus. Once the bus goes 50 miles an hour, the bomb is armed. If it drops below 50, it blows up. What do you do? What do you do?

....the DMCB gets to think about 'decremental cost effectiveness.'

This is a concept raised in a November 3 Annals of Internal Medicine article by Aaron Nelson and colleagues titled 'Much Cheaper, Almost as Good: Decrementally Cost-Effective Medical Innovation.' The authors reviewed over 2000 peer review articles on new innovative therapies that included cost and benefit in their analyses. While the majority of the innovations increased cost and benefit, there were nine articles that saved a significant amount of money in exchange for a small decrease in quality. Examples included doing percutaneous coronary interventions vs. more expensive and better open heart surgery, using watchful waiting for inguinal hernias instead of routinely operating on them and using drugs to treat reflux disease with symptomatic heartburn instead of laparascopic surgery. These treatments were almost as good, but were a heluva lot cheaper.

The point of the article is that the medical literature on medical innovation is characterized by a 'race to the top' and little attention is being paid to the economic trade-offs that routinely occur in other parts of our economy. Given our growing national interest in finding health care bargains, giving consumers the option of spending far less money is exchange for giving up a slightly greater benefit may not be so outlandish. This has implications for how comparative effectiveness research (CER) should be conducted in the short term, and what we'll need to do to bend the cost curve over the long term.

So pop quiz, hot shot. There's a health care cost inflation bomb on the body politic's bus. Once we find 2009 health reform doesn't work, that bomb is armed. If the cost curve doesn't drop, it blows up. What do you do? What do you do?

aware of the irony

Life is funny.

This morning was perfect weather for a bike ride. The sun was out and the temperature climbed to 17C (that's 62.6 in American). It was my first time on the bike in more than a week - since before the plague toppled my family, like a series of dominoes.

It was a fun ride, and I didn't even mind the big hill I have to climb on my way to the hospital. I arrived twenty minutes after I set out, a little sweaty and with my heart pumping. As I locked up and headed into the cancer centre, I noted with pleasure that I hadn't been coughing.

"It feels good to be healthy."

I very nearly said it out loud.

I was suddenly struck by the absurdity of my situation. Here I was, going to get my bloodwork done the day before chemo and thinking about how healthy I am.

Three years ago, at almost exactly this time of year, I learned that my cancer had become metastatic. I don't think I could have imagined this day, when I'd be riding my bike up Smythe Rd. and thinking about how healthy I am.

So, as I was saying at the beginning of this post - life really is pretty funny.

Cross-posted to Mothers With Cancer.

The House Health Bill--Loading More People Onto the Titanic

Our health care system is truly titanic, in more than one sense of the word.Not only is it huge, but it's also growing at unsustainable rates that undermine our health care security and fiscal stability - and threaten to sink the system under its own weight.When the health care debate began in earnest just after the November 2008 election, it was supposed to be about reform-moving the nation

Not Impressed

True, while it does take a lot to impress the Disease Management Care Blog, the House's passage of health reform legislation is not landmark, revolutionary or courageous. Rather, it is:

Just one step on the road to a Conference Committee, a closed door affair from which will emerge an entirely new bill.

A gateway to November 2010 'Midterm-istan,' where little of Mr. Obama's 2008 magic and a lot of voter concerns await our increasingly nervous politicians.

Testimony to the gap that exists between the old guard liberal Committee Chairs and the more moderate Representatives.

While complicated at 1,990 pages, it is no where close to matching - or taming - the complexity of U.S healthcare (non)system, and

A chance for readers to look at how their own Representatives stand on health reform (you can look up the name here).

Getting In Line For the Swine Flu Shot: A Physician's Story

The Disease Management Care Blog has a primary care physician buddy that has offered up his insights from time to time, and he's done it again. When he and another physician were unable to secure any of the H1N1 swine flu vaccine for themselves or their clinics, they decided to personally access the local public health system. For those of us with decent health insurance and an established relationship with a physician, the scenario below is surreal - and eye opening.

The photo is from the clinic and even with the alterations to anonymize things, the expressions speak volumes.

Draw your own lessons: this can either be an anecdote describing just how broken the system is or what happens when the government has full control. Either way, we can all agree this is something that should happen to as few people as possible.

When we arrived 10 minutes early, the first thing that struck us was how we had to enter the clinic building through a side door. The door was guarded by a burly security guard who told us that the waiting room was packed and that we would be given numbers as soon as people started exiting. As we waited in line, there were numerous sarcastic comments about nationalized health care. After almost an hour, the line we were in stretched about half a city block. The guard wondered aloud whether we’d ‘storm the castle.’

Finally, we were in the first group of twenty that were allowed in and I was given my prized laminated numbered card. Once inside, I was led up a flight of steps into the clinic waiting room that was teeming with lines leading to many doors and a longer line stretching along the near wall of a large room. We asked a clinic worker with a name tag and walkie-talkie where we should go. We were directed to the ‘reception hall’ and asked to wait until the line for registration got shorter. We waded through the lines and went to the hall with about 3 others out of the 20. The remaining 17 got in the registration line. Sometime later, a clinic worker told us to get in the registration line.

The woman in front of us was admonished for not being in a high risk group until she told the receptionist that she was here to register her child. We were luckier: our medical licenses served to verify our high risk status. We were then asked to fill out a form, which had all of the appropriate questions on them. We were then told to pick an immunization line. There were 6 rooms with frosted glass windowed doors that had long lines in front of them. We picked one and slowly made our way through the door. Two paramedics were there to greet me. One very patiently and slowly drew up the shot into a 3cc syringe with a large headspace. This is important because 1cc syringe with low headspaces are known to maximize vaccine yield, especially in times of shortage. The second paramedic patiently put on a new pair of nitrile gloves and administered the vaccine, and the first paramedic then proffered a band aid. While they reviewed my paperwork, no one verbally confirmed whether we had any allergies.

We then left.

At no time were we asked to verify our identities or addresses, nor were we asked for any insurance information. I am still wondering what the laminated number 23 was for, and had no idea where to return it to. If anyone is in need of one, please notify the DMCB blog and shipment for first class postage will be arranged.

The total experience lasted about 70 minutes from arrival to departure. It was certainly run differently than physician-based clinics. We agreed that it was nice to not have to show photo ID, insurance cards, or make a payment. The illusion of free care and no insurance hassle was kind of nice, but this was hardly the promise of Washington DC’s health care reform. We also agreed that our clinics were faster, had less staff, had more redundant system checks for allergies, conserved more vaccine and were more organized.

AMA Supports the House Democratic Health Care Bill--Take Another Look

The AMA came out in support of the House Democratic health care bill this afternoon—sort of. From their press release:“The American Medical Association (AMA) today announced support for concurrent passage of H.R. 3962 and H.R. 3961, U.S. House of Representatives health system reform bills."I would suggest the operative word is "concurrent."HR 3962 is the big House health care bill. HR 3961 is the

The House Bill Should Be Defeated on Saturday

Here's the email I just sent my Congressman, freshman "Blue Dog" Frank Kratovil of Maryland:Please vote no this weekend on the House bill.This is not health care reform.This is at least a $1 trillion entitlement expansion paid for half with only modest provider cuts and $500 billion in taxes.Real cost containment would bend the curve and produce the savings needed to accomplish universal

first one, then the other

My older son went back to school this morning. I did a little happy dance in the hall after he left. It's not that I mind having him around but the kid has to go back out into the world some time, you know?

And then of course, my six year old woke up with a sore throat. He really doesn't seem too sick to me (he had the first part of the H1N1 shot last week) but these days, I prefer to err on the side of caution (we are relieved that there is no coughing, as D. has asthma and things can get scary pretty quickly).

We've been hanging out in our pajamas on the couch. I don't know if this will help me reach my deadlines (or my NaNoWriMo goal) but it's pretty sweet.

New Cavalcade of Risk Is Up!

How assured can you be that you know everything you need to know about insurance? Find out at Debbie Dragon's WiseBread Blog - where folks learn about about living large on a small budget. Debbie has assembled the best of the bloggery on risk and finance, with some good links about health reform.

The Obama Administration's 'Top Ten' Answers to the Swine Flu Vaccine Shortage

With apologies to the David Letterman Show's Top Ten List........

10. Those long lines are only being shown on Fox News.

9. Um, hellooo... joblessness, global warming, health care reform, Afghanistan, Republican resurgence, Olympic city competition, Noble Prize winning. We'll get to it.

8. It's not a shortage. It's a temporarily prolonged lag time in vaccine availability compounding a public health emergency.

7. We said 'Yes We Can,' not 'Yes We Will.'

6. Maybe, but this also means that persons in my Administration have a personal excuse to avoid getting vaccinated.

5. There is obviously not enough Federal regulation, oversight and supervision. We intend to fix that.

4. It's not called 'Swine Flu.' It's called H1N1 and 24.8 million doses are available.

3. It's President Bush's fault!

2. It's the health insurers' and big pharma's fault!

and the number one answer......

1. We unfortunately didn't read the Disease Management Care Blog's past postings on the topic.

Image above available via Creative Commons